Can migraine cause both juxtacortical and periventricular lesions?

Migraine and White Matter Lesions: Periventricular and Juxtacortical Involvement

Migraine can cause both periventricular and juxtacortical white matter lesions, though periventricular lesions in migraine patients typically do not abut the ventricles directly and have different morphological characteristics compared to those seen in multiple sclerosis.

Prevalence and Characteristics of White Matter Lesions in Migraine

Periventricular Lesions

• Up to 30% of migraine patients can have periventricular lesions 1
• In migraine, periventricular lesions typically:
  • Do not directly abut the ventricles (have intervening normal white matter)
  • Are not oriented perpendicular to the ventricles
  • Do not have the "Dawson's fingers" appearance characteristic of MS lesions 1
  • Are generally small, punctate hyperintensities 2

Juxtacortical Lesions

• Juxtacortical lesions can occur in migraine patients 1, 3
• In migraine, juxtacortical lesions typically:
  • Are located in frontal, parietal, and temporal lobes (in decreasing order of frequency) 3
  • Appear as round or slightly elongated foci with a median size of 2.5mm 3
  • Are separated from the cortex by a rim of normal white matter (unlike MS lesions which directly abut the cortex) 1

Differentiating Migraine-Related Lesions from Multiple Sclerosis

The distinction between migraine-related white matter lesions and those of MS is important for accurate diagnosis:

Key Differentiating Features

1. Number of periventricular lesions: The presence of ≥3 periventricular lesions significantly increases specificity for MS versus migraine with aura 4

2. Morphology and location:

   • MS lesions: Ovoid shape, perpendicular to ventricles, directly abutting ventricles 1
   • Migraine lesions: Small, punctate, often not directly touching ventricles 2

3. Distribution pattern:

   • Migraine lesions: More commonly found in deep white matter and juxtacortical regions 5
   • MS lesions: Characteristic distribution in periventricular areas, corpus callosum, infratentorial regions, and spinal cord 1

Clinical Implications

• White matter hyperintensities in migraine patients without vascular risk factors show similar patterns across different migraine subtypes (chronic vs. episodic, with vs. without aura) 3

• The number of lesions in the frontal lobe juxtacortical white matter correlates with:

  • Patient age
  • Duration since migraine onset 3

• White matter lesions in migraine patients are generally considered nonspecific and of unclear clinical significance 2

• When evaluating white matter lesions in migraine patients, it's important to consider other potential diagnoses such as CADASIL, particularly when lesions involve the anterior temporal pole, external capsule, basal ganglia, and/or pons 2

Imaging Considerations

• Synthetic T2-FLAIR and synthetic double inversion recovery (DIR) sequences may detect more lesions in deep and juxtacortical white matter compared to conventional T2-FLAIR in migraine patients 5

• No significant difference has been observed in the detection of periventricular lesions across these sequences 5

In summary, while migraine can cause both periventricular and juxtacortical white matter lesions, they typically have distinct characteristics from those seen in demyelinating disorders like MS. The presence of three or more periventricular lesions that directly abut the ventricles should raise suspicion for MS rather than migraine as the primary cause.